Date __________________ 		        PATIENT INFORMATION 			         
Name _____________________________________________________________ Prefers to be called _________________________
Street Address ___________________________________________ City _____________________ State ______ Zip ____________
Phone (____)______________________ Email _____________________________________________________ Sex: M (   ),  F (   ) 
Date of Birth ________________ Age _______ School/Employer __________________________________________ Grade ______
Responsible Party ___________________________________ Relationship to Patient ______________ SS# ____________________
Emergency Contact __________________________________ Relationship to Patient ______________ Phone (___)______________
Dentist ______________________________ Last dental visit _________________ Referred by ______________________________
IF PATIENT IS A MINOR
Parent/guardian __________________________________ Marital Status: Married (   ), Separated (   ), Divorced (   ), Widowed (   )
Street Address (if different)_____________________________________ City ____________________ State ______ Zip _________
Phone (____)___________ Email _______________________________ Employer _____________________ Role ______________
Additional parent/guardian _________________________  Marital Status: Married (   ), Separated (   ), Divorced (   ), Widowed (   )
Phone (____)___________ Email _______________________________ Employer _____________________ Role ______________
Patient Siblings (ages) _______________________________________________________Hobbies ___________________________

INSURANCE INFORMATION
Primary Insurance
Policyholder_____________________________________ Relationship to Patient __________________ D.O.B. ________________
Insurance company _______________________________ Phone (____)__________ Employer ______________________________
Policy/Member ID# ___________________________________ Group # ______________________ SS# ______________________
Insurance Address ________________________________________ City ____________________ State ______ Zip _____________
Secondary Insurance
Policyholder_____________________________________ Relationship to Patient __________________ D.O.B. ________________
Insurance company _______________________________ Phone (____)__________ Employer ______________________________
Policy/Member ID# ___________________________________ Group # ______________________ SS# ______________________
Insurance Address ________________________________________ City ____________________ State ______ Zip _____________

□ I understand a copy of the Summary of Privacy Practices is available upon request.
□ I authorize □ I do not authorize Pollei Orthodontics to use voicemail, email or fax to communicate appointment, financial, insurance, or medical record information
Release of Benefits & Information: I authorize my insurance benefits to be paid directly to the doctor. I am financially responsible for any balance due. I authorize the doctor or insurance company to release any information required for this claim.
Signed: ____________________________________________________________________ Date: ______________________

PATIENT'S HEALTH HISTORY

Physician ______________________________ Office phone number (____)___________ Date of most recent visit ______________ 
Recent changes in your health______________________ Currently receiving treatment for __________________________________
Current medications being taken _________________________________ Ever taken Phen-Fen, Fosamax, or bisphosphonates? _____
						YES	NO						YES	NO
Abnormal bleeding or hemophilia			□	□	ADHD or other neurodiversity		□	□
Allergy to medicines or food			□	□	Arthritis or joint disease			□	□
Allergy to metal, latex or plastic			□	□	Artificial bones, joints, or valves		□	□
Asthma/hay fever      				□	□	Cancer, chemotherapy or radiation		□	□
Lung/breathing problems				□	□	Epilepsy, seizures, or fainting spells	□	□
Heart murmur, defect, surgery or other conditions	□	□	Diabetes					□	□
Blood pressure anomalies				□	□	Kidney problems				□	□
Past hospital stay or operation			□	□	Liver problems or hepatitis		□	□
History of drug, alcohol, tobacco or marijuana use?	□	□	Thyroid disease, TB, or immune problems	□	□
Explain all yes answers noted above along with any other medical consideration not listed above: _____________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DENTAL/ORTHODONTIC HISTORY
What is the primary thing you wish for orthodontic treatment to improve? ________________________________________________
Has the patient been evaluated for orthodontic treatment before? _______ If yes, how long ago _______________________________
Has there ever been trauma to the patient's face or teeth? _______ If yes, please describe ____________________________________
Does the patient have a history of a thumb or finger habit? ______ Musical instruments played _______________________________
Is there a family history of extra or missing teeth? ______________ Any history of TMJ pain or disfunction? ___________________
For adolescent patients: Has puberty begun ___________________ Date menstruation began (females) ________________________

I declare that the information that I have provided is correct to the best of my knowledge. I understand it will be protected consistent with HIPAA privacy laws. I acknowledge that it is my responsibility to inform this office of any medical status changes for the patient for whom these questions have been answered.
____________________________________________________________________________   		__________________
Signature of patient (or parent/guardian if the patient is a minor)				Date